Observational analysis highlights risks of lost surgical specimens in perioperative settings, indicating improved specimen management is crucial.
AORN JournalVolume 122, Issue 4 pp. 249-255 Safety First Preventing Lost Surgical Specimens Earn 1.3 Contact Hours Ray-an B. Talatala DNP, RN, CNOR, NPD-BC, FAORN, Corresponding Author Ray-an B. Talatala DNP, RN, CNOR, NPD-BC, FAORN [email protected] Search for more papers by this author Ray-an B. Talatala DNP, RN, CNOR, NPD-BC, FAORN, Corresponding Author Ray-an B. Talatala DNP, RN, CNOR, NPD-BC, FAORN [email protected] Search for more papers by this author First published: 29 September 2025 https://doi.org/10.1002/aorn.14419Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookxLinkedInRedditWechatBluesky REFERENCES 1Nordin N, Ab Rahim SN, Wan Omar WFA, et al. Preanalytical errors in clinical laboratory testing at a glance: source and control measures. Cureus. 2024; 16(3):e57243. https://doi.org/10.7759/cureus.57243 10.7759/cureus.57243 PubMed Google Scholar 2 Guideline for specimen management. In: Guidelines for Perioperative Practice. AORN Inc; 2020. Accessed June 20, 2025. https://aornguidelines.org/guidelines/content?sectionid=173724676&view=book Google Scholar 3 Serious Reportable Events in Healthcare—2011 Update: A Consensus Report. National Quality Forum; 2011. Accessed August 13, 2025. https://cms.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=69573 Google Scholar 4 Reducing specimen errors. Leadership Insights. AORN J. 2019; 109(4): 496-499. https://doi.org/10.1002/aorn.12658 10.1002/aorn.12658 PubMed Google Scholar 5Heher YK. Specimen almost lost. Agency for Healthcare Research and Quality: PSNet. November 1, 2017. Accessed June 12, 2025. https://psnet.ahrq.gov/web-mm/specimen-almost-lost Google Scholar 6Steelman VM, Williams TL, Szekendi MK, Halverson AL, Dintzis SM, Pavkovic S. Surgical specimen management: a descriptive study of 648 adverse events and near misses. Arch Pathol Lab Med. 2016; 140(12): 1390-1396. https://doi.org/10.5858/arpa.2016-0021-OA 10.5858/arpa.2016-0021-OA PubMed Web of Science® Google Scholar 7Santana MF, de Lima Ferreira LC. Errors in surgical pathology laboratory. In: GS Zaman, ed. Quality Control in Laboratory. InTechOpen; 2018. https://doi.org/10.5772/intechopen.72919 10.5772/intechopen.72919 Google Scholar 8Farb J, Gordon LV, Minter HM, et al. Clinical Labs: Studies Suggest Biopsy Specimen Misidentification and Contamination Errors Are Infrequent. US Government Accountability Office. November 2020. Accessed June 12, 2025. https://www.gao.gov/assets/gao-21-59.pdf Google Scholar 9Tran NK, Liu Y. Pre-analytical pitfalls: missing and mislabeled specimens. Agency for Healthcare Research and Quality: PSNet. February 26, 2020. Accessed June 12, 2025. https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens Google Scholar 10Carmack HJ, Lazenby BS, Wilson KJ, Bakkum-Gamez JN, Carranza L. Lost, mislabeled, and mishandled surgical and clinical pathology specimens: a systematic review of published literature. Am J Clin Pathol. 2024; 162(4): 349-355. https://doi.org/10.1093/ajcp/aqae055 10.1093/ajcp/aqae055 PubMed Web of Science® Google Scholar 11Kinlaw TS, Whiteside D. Surgical specimen management in the preanalytic phase: perioperative nursing implications. AORN J. 2019; 110(3): 237-250. https://doi.org/10.1002/aorn.12782 10.1002/aorn.12782 PubMed Web of Science® Google Scholar 12Fleming KA, Naidoo M, Wilson M, et al. High-quality diagnosis: an essential pathology package. In: DT Jamison, H Gelband, S Horton, et al, eds. Disease Control Priorities: Improving Health and Reducing Poverty. 3rd ed. The International Bank for Reconstruction and Development/The World Bank; 2017. Accessed June 12, 2025. https://www.ncbi.nlm.nih.gov/books/NBK525286/ 10.1596/978-1-4648-0527-1_ch11 Google Scholar 13Cornes M. The preanalytical phase – past, present and future. Ann Clin Biochem. 2020; 57(1): 4-6. https://doi.org/10.1177/0004563219867989 10.1177/0004563219867989 PubMed Web of Science® Google Scholar 14D'Angelo R, Mejabi O. Getting it right for patient safety: specimen collection process improvement from operating room to pathology. Am J Clin Pathol. 2016; 146(1): 8-17. https://doi.org/10.1093/ajcp/aqw057 10.1093/ajcp/aqw057 PubMed Web of Science® Google Scholar 15The AMC PSO. Patient Safety Guidance for Pathology Specimens: Identifying and Mitigating Risks for Specimen Loss and Mishandling Resulting in Diagnostic Error. Academic Medical Center Patient Safety Organization; 2022. Accessed June 12, 2025. https://www.rmf.harvard.edu/Risk-Prevention-and-Education/Guidelines-and-Algorithms-Catalog-Page/Guidelines-Algorithms/2022/Guidelines-for-Mitigating-Risk-with-Pathology-Specimens-AMC-PSO Google Scholar 16Mcleod RWJ, Myint-Wilks L, Davies SE, Elhassan HA. The impact of noise in the operating theatre: a review of the evidence. Ann R Coll Surg Engl. 2021; 103(2): 83-87. https://doi.org/10.1308/rcsann.2020.7001 10.1308/rcsann.2020.7001 PubMed Web of Science® Google Scholar 17Qualey B. Preventing surgical pathology specimen loss. Presented at: Showcase for Hopkins Inquiry and Nursing Excellence (SHINE) Conference 2023. April 18, 2023. Accessed June 12, 2025. https://www.hopkinsmedicine.org/-/media/nursing/documents/cni-documents/jhbmc_podium_qualeyr.pdf Google Scholar 18Spruce L. Specimen management. AORN J. 2021; 113(5): 505-513. https://doi.org/10.1002/aorn.13378 10.1002/aorn.13378 PubMed Web of Science® Google Scholar 19Link T. Guidelines in practice: specimen management. AORN J. 2021; 114(5): 443-455. https://doi.org/10.1002/aorn.13518 10.1002/aorn.13518 PubMed Web of Science® Google Scholar 20Yu MH, Lee TT, Mills ME. The effect of barcode technology use on pathology specimen labeling errors. AORN J. 2019; 109(2): 183-191. https://doi.org/10.1002/aorn.12585 10.1002/aorn.12585 PubMed Web of Science® Google Scholar 21Stanton C. Keeping up with technology. AORN J. 2011; 93(1):C1, C8-C9. https://doi.org/10.1016/S0001-2092(10)01271-8 10.1016/S0001?2092(10)01271?8 PubMed Google Scholar 22Horning MA, Taylor-Pearson ZA. Nurse leaders as influencers of knowledge to practice. Worldviews Evid Based Nurs. 2024; 21(3): 230-233. https://doi.org/10.1111/wvn.12726 10.1111/wvn.12726 PubMed Web of Science® Google Scholar 23Alsadaan N, Salameh B, Reshia FAAE, et al. Impact of nurse leaders behaviors on nursing staff performance: a systematic review of literature. Inquiry. 2023; 60. https://doi.org/10.1177/00469580231178528 10.1177/00469580231178528 Web of Science® Google Scholar 24 UC Davis PSNet Editorial Team. Patient Safety Primer. Culture of safety. Agency for Healthcare Research and Quality. September 15, 2024. Accessed June 12, 2025. https://psnet.ahrq.gov/primer/culture-safety Google Scholar 25Shah PD. Patient safety and quality for office-based procedures in otolaryngology. Otolaryngol Clin North Am. 2019; 52(1): 89-102. https://doi.org/10.1016/j.otc.2018.08.015 10.1016/j.otc.2018.08.015 PubMed Web of Science® Google Scholar 26Bojic Z. Introduction to FMEA. Systemico. Accessed June 12, 2025. http://www.systemico.ca/quality-and-risk-management/failure-mode-and-effects-analysis-fmea/introduction-to-fmea/ Google Scholar 27Dawson A. A practical guide to performance improvement: Failure Mode and Effects Analysis. AORN J. 2019; 110(3): 282-287. https://doi.org/10.1002/aorn.12780 10.1002/aorn.12780 PubMed Web of Science® Google Scholar Volume122, Issue4October 2025Pages 249-255 ReferencesRelatedInformation
No takes yet. Share an insight, caveat, or question.
Ray‐an B. Talatala (2025) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: